Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. "Weight gain is a common but troubling side effect."
Weight gain is indeed a known side effect of lithium treatment, and acknowledging this can validate the client's experience.
B. "What have you been eating? Weight gain is not usually associated with lithium."
This response could be perceived as blaming and does not acknowledge that weight gain can be a side effect of lithium.
C. "Weight gain occurs only during the first month of treatment with this drug."
This statement is misleading as weight gain can occur beyond the first month of treatment with lithium.
D. "That's strange. Weight loss is the typical pattern."
This statement is incorrect as weight loss is not the typical pattern associated with lithium; weight gain is more common.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health Proctored Exam (East Los Ángeles College). Take the full exam now
Full Explanation
Choice A reason: Weight gain is indeed a known side effect of lithium treatment, and acknowledging this can validate the client's experience.
Choice B reason: This response could be perceived as blaming and does not acknowledge that weight gain can be a side effect of lithium.
Choice C reason: This statement is misleading as weight gain can occur beyond the first month of treatment with lithium.
Choice D reason: This statement is incorrect as weight loss is not the typical pattern associated with lithium; weight gain is more common.
Similar Questions
A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.
A. Check the client's pupil reactivity.
Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.
B. Perform a developmental screening test.
Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.
C. Prepare the client for a CT scan.
Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed
D. Obtain a urine specimen.
Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.
E. Monitor the client’s vital signs frequently.
Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.
Full Explanation
Choice A Reason:
Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.
Choice B Reason:
Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.
Choice C Reason:
Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.
Choice D Reason:
Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.
Choice E Reason:
Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.
Which of the following statements is associated with a client's child experiencing hair loss?
A. "I think it is the shampoo and conditioner my child is using."
This statement suggests a possible external cause for the hair loss, which might not be related to a psychological issue.
B. "I have watched my child pull hair out and try to hide it."
Observing the child pulling out hair and attempting to conceal it indicates trichotillomania, a disorder characterized by a compulsive urge to pull out one's hair.
C. "I started losing some hair at a young age and think it's just shedding."
Genetic factors could contribute to hair loss, but the statement does not directly suggest a behavioral or psychological disorder.
D. "My child doesn't appear to be nervous or upset about anything."
The lack of apparent nervousness or upset in the child does not rule out psychological reasons for hair loss, such as trichotillomania, which can sometimes be a covert behavior.
Full Explanation
Choice A reason: This statement suggests a possible external cause for the hair loss, which might not be related to a psychological issue.
Choice B reason: Observing the child pulling out hair and attempting to conceal it indicates trichotillomania, a disorder characterized by a compulsive urge to pull out one's hair.
Choice C reason: Genetic factors could contribute to hair loss, but the statement does not directly suggest a behavioral or psychological disorder.
Choice D reason: The lack of apparent nervousness or upset in the child does not rule out psychological reasons for hair loss, such as trichotillomania, which can sometimes be a covert behavior.
The nurse has established a therapeutic relationship with a client. Which behaviors indicate that the client has entered into the identification phase of the nurse-client relationship?
A. The client is attending all therapy sessions and utilizing the services provided.
Attending all therapy sessions and utilizing services indicates cooperation but does not specifically reflect the identification phase, which is characterized by deeper emotional connections.
B. The client states that they feel the issues have been resolved and no longer need to come.
Stating that issues have been resolved and no longer needing to come may suggest a conclusion to the therapeutic relationship rather than the development of the identification phase.
C. The client is sharing feelings and emotions with the nurse.
Sharing feelings and emotions with the nurse is indicative of the identification phase, where the client starts to see the nurse as a supportive figure and begins to identify with them.
D. The client is answering questions related to the plan of care.
Answering questions related to the plan of care shows engagement but does not necessarily indicate the identification phase's emotional connection.
Full Explanation
Choice A reason: Attending all therapy sessions and utilizing services indicates cooperation but does not specifically reflect the identification phase, which is characterized by deeper emotional connections.
Choice B reason: Stating that issues have been resolved and no longer needing to come may suggest a conclusion to the therapeutic relationship rather than the development of the identification phase.
Choice C reason: Sharing feelings and emotions with the nurse is indicative of the identification phase, where the client starts to see the nurse as a supportive figure and begins to identify with them.
Choice D reason: Answering questions related to the plan of care shows engagement but does not necessarily indicate the identification phase's emotional connection.